style="font-size:15px;"> Trowell and his colleagues used biopsies or specimens taken from live patients as part of their efforts to understand these unusual fat deposits in the liver. As Trowell later described the procedure, it is clear that liver biopsies were dangerous and in at least one instance resulted in a patient’s death: “We would put . . . [the patients] under an anaesthetic, and would put in a large bore needle, with which I could suck a small thread out. . . . I wasn’t doing it with as good needles as they have now. We hadn’t lost any children. We . . . had lost one adult over this . . . because I hadn’t realized how deep you could go in on a thin patient. It had made him bleed, I am afraid fatally.”43 Biopsies causing even one patient to die could alone generate local concerns, yet when it came to biopsies performed on young children, witnesses may have also had reasons to conflate biopsies with blood work. Trowell began conducting liver biopsies on young children after acquiring a special bore needle from Joseph and Theodore Gilman during a visit to South Africa in 1947.44 When Trowell demonstrated the procedure at a conference, he reported that in the fifty to sixty biopsies he had performed on severely malnourished children, “almost invariably he had found that the liver was being pushed forward and that blood collected in the syringe.”45 Thus, in this period, biopsies and blood extraction and the relative dangers of each procedure were, for all intents and purposes, largely indistinguishable.
Biopsies were also routinely performed alongside blood tests, further blurring the distinction. This was particularly true of the nitrogen balance studies carried out at the physiology and biochemistry lab. As nitrogen is a primary component of all proteins and a by-product of protein metabolism, measuring the amount of nitrogen consumed and then excreted was the most effective way of quantifying the amount of protein used by the body. Highlighting the extent of the extraction involved in these investigations, one nitrogen balance study entailed closely measuring the nitrogen consumed and excreted in addition to collecting liver biopsies, blood for red blood cell counts, and serum protein estimations, repeatedly throughout the duration of the study. In order to obtain the most accurate results, the nitrogen balance studies were extended until, as one researcher noted, “the patient had to be granted discharge, or in default of that, absconded, from hospital.” This meant that in some cases the investigation lasted for an astonishing 170 days.46 Exact figures for the number of participants were not provided, but one report indicated that “the limit indeed, was not the supply of cases, but the working capacity of the laboratory,”47 suggesting that the number of people involved in this particular set of studies may have been considerable.
During the Second World War, Trowell also sent liver specimens to Professor Harold Himsworth at the University College in London. Himsworth became interested in Trowell’s work when, in the context of wartime rationing, he was asked to determine the dietary protein requirements of young children. As very little was then known about the repercussions of protein deficiency, Himsworth began conducting experiments with rats and found that, like Trowell’s patients, when deprived of protein they developed a fatty liver, discolored hair, and even slight edema.48 Himsworth then became a key advocate of Trowell’s work. Trowell preserved the liver specimens from his severely malnourished patients in his home refrigerator until they could be transported to England: “I would keep the bit refrigerated until I could take it to the plane, in the hope that it hadn’t ‘gone bad’, as you might say, by the time it got to London. I’d put some of it in pickle sometimes.”49 He would, of course, as he later explained, warn his wife by letting her know “look, you mustn’t let the boys cook this.”50 What the “boys” who cooked for Trowell and his family thought of the pickled liver specimens that were kept in the home refrigerator will probably never be known. It is, nonetheless, likely that such practices spurred scandalous rumors about the colonial medical officer conducting research on severely malnourished children.
The breakthrough in the search for the etiology of the condition finally came at the end of the Second World War when a new pathologist, Jack Davies, joined the staff at Mulago. Davies was already aware of Trowell’s nutritional research before he arrived in Uganda, and, unlike his predecessor, was eager to assist in future nutritional studies. He immediately agreed to conduct thorough postmortem examinations, and in the first child he examined, Davies found the long-awaited pathological link between the highly fatal condition and protein deficiency. The child’s pancreas was atrophied and the degenerate condition of the pancreatic cells indicated that the child’s pancreas had not been secreting digestive enzymes. This crucial discovery appeared to substantiate Williams’s protein hypothesis, as enzyme synthesis is dependent on adequate supplies of dietary protein. It was then that, in order to honor Williams and her foresight, Trowell began to refer to the condition as kwashiorkor. Pancreatic atrophy also explained why severely malnourished children were not easily treated. Even protein-rich foods like milk were of limited therapeutic value without sufficient protein to produce the digestive enzymes needed to breakdown and absorb essential nutrients. It was a vicious cycle: children suffering from severe acute malnutrition simply could no longer fully digest and absorb the food they consumed.51
To verify that the pancreatic atrophy occurred prior to death and not as part of a process of rapid decomposition, it was necessary to perform further autopsies within twenty minutes of the child’s death. This was not possible during the day when both Trowell and his colleagues were needed in the hospital wards. “It was possible at night if,” as Davies explained, he and Trowell “coordinated well.” Trowell would inform Davies that “he had a dying child expected to die in the night . . . [and Davies] would wait ready in the morgue . . . till a scuffle outside indicated Hugh’s arrival with the body of the sad victim he had pronounced dead only a few minutes before.”52 So little time had passed between when the children were pronounced dead and their delivery to the morgue that according to Davies, “usually the muscle twitched as [he] rapidly did a postmortem getting the essential organs into fixative as the time dictated.”53 Trowell and his colleagues were aware of the sensitivity that such work required and did take precautions. They would only remain in the morgue long enough to get the specimens into the fixative, and would wait until the next morning when they were delivered to the laboratory to analyze them. “For,” as Davies explained, “never were Europeans allowed by the staff to carry anything other than papers from the morgue. This was in deference to local feelings. . . . Autopsies performed by Europeans in Mulago Hospital were closely watched, as were the pathologists. It would have been a very upsetting thing if a new pathologist, lithe and slender had become stout for the darkest suspicions would be aroused.”54 In the end, as we will see, such precautions proved to be insufficient and did little to assuage a growing set of local concerns.
This important development in the long search for the etiology of kwashiorkor came at a significant moment in the rise of international medicine. In October 1949, an Expert Committee on Nutrition formed jointly by the United Nations Food and Agricultural Organization (FAO) and the World Health Organization (WHO) held its first meeting in Geneva. Kwashiorkor, described as “one of the most widespread nutritional disorders in tropical and sub-tropical areas,” was high on the agenda, and Trowell was asked to prepare a memorandum on the condition for the committee’s consideration.55 The committee resolved to conduct an investigation of kwashiorkor in sub-Saharan Africa beginning with a visit to Mulago Hospital in order to first consult Trowell and his colleagues in Uganda. The subsequent WHO report, Kwashiorkor in Africa, was based in large part on evidence from Mulago and became the seminal study in the growing international focus on protein malnutrition.56 A second meeting of the Joint FAO/WHO Expert Committee on Nutrition centered largely on discussions of this seminal report, concluding with a resolution to conduct further surveys.57 Delegations later sent to Central America and Brazil confirmed that kwashiorkor was a worldwide problem requiring immediate action.58
The pathological evidence that appeared to connect the condition to protein deficiency did not immediately gain widespread acceptance, however, especially in Uganda. The pancreatic atrophy explained why it was so difficult to treat severely malnourished children, but it did not provide a clear way to address this problem. Experiments with pounded steak and desiccated
